The public health legacy of slav­ery

Baltimore Sun Sunday - - COMMENTARY - By Lisa A. Cooper and Jeremy Greene

It has been 400 years since the first en­slaved Africans ar­rived in the Bri­tish colonies, yet the bod­ies of many Amer­i­cans today are still marked by the ef­fects of that horrible in­sti­tu­tion. Across the na­tion, African Amer­i­can adults have death rates from heart dis­ease that are about one and a quar­ter times higher than white adults. African Amer­i­can women ex­pe­ri­ence preg­nancy-re­lated deaths three to four times more than their white coun­ter­parts.

In Bal­ti­more, th­ese dis­par­i­ties are writ­ten on the map, with pre­dom­i­nantly AfricanAme­r­i­can neigh­bor­hoods of the “Black but­ter­fly” of East and West Bal­ti­more show­ing life­spans 14 to 20 years shorter than those of largely white neigh­bor­hoods in the “White L” through the city’s cen­ter.

As pri­mary care physi­cians work­ing in a com­mu­nity health cen­ter across from the Latrobe Homes hous­ing project, down the street from the jail com­plex, both of us go to work each week to con­front the mas­sive health in­equities that are re­al­i­ties for African Amer­i­cans.

Th­ese evils stem from the racial de­mar­ca­tion of ur­ban neigh­bor­hoods from redlin­ing poli­cies, to our carceral sys­tems and seg­re­gated in­sti­tu­tions from Jim Crow, down the tracks of the Great Mi­gra­tion, past the failed prom­ises of Re­con­struc­tion to the bod­ily harms and psy­cho­log­i­cal trauma of plan­ta­tion life. They can be traced to the Fells Point wa­ter­front where Har­riet Tub­man hid slaves she helped es­cape, to the slave mar­kets where Power Plant Live now en­ter­tains us and to the ships of the mid­dle pas­sage that killed more than 2 mil­lion en­slaved Africans be­fore they reached Amer­i­can shores.

Michelle Sim­mons, a mother and grand­mother on the Johns Hop­kins Cen­ter for Health Eq­uity com­mu­nity ad­vi­sory board, can feel the weight of this history. She grew up watch­ing her par­ents strug­gle, hav­ing to choose be­tween buy­ing medicine or din­ner. Her loved ones suf­fered from heart dis­ease, em­phy­sema, di­a­betes and cancer. Her mother died of a heart at­tack at 68, and her cousin died from di­a­betes at 62.

And, the his­to­ries of the public health of­ten over­look the dis­cov­er­ies and con­tri­bu­tions of en­slaved African Amer­i­cans — like the African slave Ones­imus, who taught the prin­ci­ples of small­pox inoc­u­la­tion to Bos­ton min­is­ter Cot­ton Mather in 1721. Th­ese his­to­ries of­ten erase the role of public health in­sti­tu­tions in ex­ac­er­bat­ing health in­equities. Most in­fa­mously is the role of the United States Public Health Ser­vice in ini­ti­at­ing and con­tin­u­ing the Tuskegee Study of Un­treated Syphilis from 1932-1972, openly de­ceiv­ing 600 black share­crop­pers and their fam­i­lies in Alabama and sought to pre­vent treat­ment for syphilis over the next 40 years.

The his­to­ries we tell of­ten omit the role of the health care sys­tem in per­pet­u­at­ing dis­par­i­ties, whether through de­liv­er­ing dis­parate care, re­gard­less of in­come or in­sur­ance; in­ad­e­quate sup­port of the providers and sys­tems that serve poor and mi­nor­ity com­mu­ni­ties; in­sti­tu­tions’ dis­crim­i­na­tory ad­mis­sions and hir­ing prac­tices; and the lack of in­clu­sion of African Amer­i­cans and other mi­nori­ties in po­si­tions of lead­er­ship.

To move for­ward, we must con­front th­ese era­sures. We are en­cour­aged that across the coun­try, dis­par­i­ties in years of life lost (a mea­sure of pre­ma­ture death) be­tween African Amer­i­cans and whites de­creased be­tween 1990 and 2014, par­tic­u­larly in 20- to 64-year-old adults. While some of this re­duc­tion can be at­trib­uted to de­creas­ing life ex­pectancy among whites, some can be at­trib­uted to gains in life ex­pectancy among African Amer­i­cans.

We are also en­cour­aged that un­der the Bal­ti­more City Health De­part­ment B’More for Healthy Ba­bies pro­gram, which pro­vides lo­cal fam­i­lies with ma­ter­nal and in­fant health ser­vices and sup­port, the in­fant mor­tal­ity rate per 1,000 live births in Bal­ti­more City fell by 38% be­tween 2009 and 2015. Th­ese ef­forts are slowly re­duc­ing the health di­vide that has char­ac­ter­ized the African Amer­i­can ex­pe­ri­ence since 1619.

For other mean­ing­ful in­ter­ven­tions, city, state and fed­eral poli­cies need to be in­formed by a com­bi­na­tion of his­tor­i­cal anal­y­sis, com­mu­nity en­gage­ment, epi­demi­o­log­i­cal re­search and im­ple­men­ta­tion science, con­ceived and car­ried out with peo­ple whose daily lives re­flect the legacy of his­tor­i­cal and on­go­ing in­jus­tices. Health pro­fes­sion­als and schol­ars can­not suc­ceed with­out un­der­stand­ing the bit­ter roots of th­ese health in­equities. In­jus­tice can­not be re­solved with­out ac­knowl­edg­ing and ad­dress­ing its ori­gins.

Dr. Lisa A. Cooper ([email protected]) is di­rec­tor of the Cen­ter for Health Eq­uity at Johns Hop­kins. Dr. Jeremy Greene ([email protected] jhmi.edu) is a pro­fes­sor at Johns Hop­kins.

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